Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda

Background: Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K. Methods: UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality. Results: 1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow=3.61, p<.001 to Red (with alarm)=7.80, p<.01). Likelihood for trauma patients, however, was not significantly increased (OR:Yellow=.84, p=.75 to Red (with alarm)=1.50, p=.65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91). Conclusion: The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda

Association between multivitamin supplementation and mortality among patients with Ebola virus disease: an international multisite cohort study

Introduction: Micronutrient supplementation is recommended in Ebola Virus Disease (EVD) care; however, there is limited data on its therapeutic effects. Methods: This retrospective cohort study included patients with EVD admitted to five Ebola Treatment Units (ETU) in Sierra Leone and Liberia during September 2014 to December 2015. A uniform protocol was used to guide ETU care, however, due to supply limitations, only a subset of patients received multivitamins. Data on demographics, clinical characteristics, and laboratory testing was collected. The outcome of interest was facility based mortality and the primary predictor was multivitamin supplementation initiated within 48 h of admission. The multivitamin formulations included: thiamine, riboflavin, niacin and vitamins A, C, and D3. Propensity score models (PSM) were used to match patients based on covariates associated with multivitamin administration and mortality. Mortality between cases treated and untreated within 48 h of admission were compared using generalized estimating equations to calculate relative risk with bootstrap methods employed to assess statistical significance. Results: There were 424 patients with EVD who had sufficient treatment data for analysis, of which 261 (61.6%) had daily multivitamins initiated within 48 h of admission. The mean age of the cohort was 30.5 years and 59.4% were female. In the propensity score matched analysis, mortality was 53.5% among patients receiving multivitamins and 66.2% among patients not receiving multivitamins, resulting in a relative risk for mortality of 0.81 (p=0.03) for patients receiving multivitamins. Conclusion: Early multivitamin supplementation was associated with lower overall mortality. Further research on the impact of micronutrient supplementation in EVD is warranted

Assessing the impact of an emergency trauma course for senior medical students in Kenya

Introduction:Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers.Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries.Methods:A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret,Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the pairedt-test, mean written, simulation and confidence scores were compared pre-course,immediately post-course and nine months post-course.Results:Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9%post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1­5). Ten out of 22 (45.5%) students were re-evaluated nine months post- course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1­5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively.Conclusion: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained

Development of emergency medicine in Rwanda

"Rwanda; known as the ""Land of a Thousand Hills;"" is a small; East African country that was the site of the devastating 1994 genocide. In the past 18years; this post-conflict country has made tremendous progress in rebuilding itself and its health infrastructure. The country has recovered or surpassed many of its pre-1994 health levels; including reduction in HIV/AIDS prevalence; under-five mortality and road traffic accidents. Nevertheless; Rwanda continues to face a high burden of disease. The leading causes of mortality in Rwanda include complications of HIV/AIDS and related opportunistic infections; severe malaria; pulmonary infections; and trauma; and are best managed with emergency and acute care services. However; health care personal resources remain significantly lacking; and there is currently no emergency medicine-trained workforce. The Rwandan government; partnering with international organizations; has launched a campaign to improve human resources for health; and as a part of that effort the creation of training programs in emergency medicine is now underway. The Rwandan Human Resources for Health program can serve as a guide to the development of similar programs within other African countries. The emergency medicine component of this program includes two tracks: a 2-year postgraduate diploma course; followed by a 3-year Masters of Medicine in Emergency Medicine. The program is slated to graduate its first cohort of trained Emergency Physicians in 2017."